(Updated) The South Dakota prairie is a world away from the luxury hotels of New York City, where the late Leona Helmsley ruled a $5 billion real estate empire. But it is here, in the grassy plains and rugged hills of the upper Midwest, that $100 million of her fortune is driving new development.

It’s not an investment in real estate. Rather, the Helmsley Trust is building “telehealth” programs, designed to bring high-quality health care to sparsely populated areas. Much of the money is going to developing virtual trauma and intensive care units in remote locations, all linked to a state-of-the-art medical center in Sioux Falls. With the push of a red alarm button, for example, a lone nurse at a tiny 26-bed hospital, working in the dead of night, can now beam an image of herself and her patient to a screen at the Sioux Falls hub. Trauma specialists and clinical pharmacists can use the electronic portal to help the nurse make a diagnosis and prescribe the proper treatment; patients’ vitals can be monitored remotely 24/7.

Why South Dakota, where “co-op” isn’t an apartment, but a place to study crop rotation? The need is intense — in South Dakota, just 800,000 people live in the state’s 77,000 square miles. Many counties in the upper Midwest are still classified by the government as “frontier” because they are home to fewer than seven people per square mile. Fewer residents mean fewer doctors and clinics.

South Dakota also happens to be home to Walter Panzirer, 34, a former small-town cop and one of Leona Helmsley’s grandchildren. He’s a trustee of the Leona B. and Harry M. Helmsley Charitable Trust, which has two offices: one on Park Avenue and the other in a Sioux Falls office park.

“We are trying to honor Mrs. Helmsley’s longstanding tradition of charitable giving,” Panzirer told TIME. Indeed, Hemsley was a huge philanthropist — giving millions to New York hospitals, cancer and juvenile diabetes research, aid to Hurricane Katrina victims, 9/11 widows and other causes. But her generosity when she was alive was largely overshadowed by stories of her volatile and often tyrannical personality; she entranced tabloid editors as the “Queen of Mean” and was convicted of tax evasion in 1989. “Only the little people pay taxes,” she was famously quoted as saying.

Panzirer says he wanted to put Helmsley’s money where it was needed most. So the Trust enlisted the Rockefeller Philanthropy Advisors to find the need; the group’s study found that six upper Midwest states — the Dakotas, Wyoming, Nebraska, Minnesota and Iowa — had received just 1.3% of all charitable donations for health care in 2007, and some 80% of that went to the Mayo Clinic in Rochester, Minn. “I would go to Timbuktu if that’s where the need is,” says the shy, soft-spoken Panzirer, who has also worked as a firefighter and paramedic. “This is an area of great opportunity; an area of great needs. We think if [eCare] can work out here, it can work anywhere. It’s the perfect incubation area, the perfect proving ground.”

The Helmsley lore is that she would have preferred to give her fortune to dogs. When the hotelier passed away in 2007, she left $12 million to her pet Maltese, Trouble (a judge later knocked Trouble’s inheritance down to $2 million). Helmsley put the bulk of her $5 billion into the charitable trust. In a mission statement, she asked that the money be used to benefit dogs and “such other charitable activities as the Trustees shall determine.” A judge ruled that the trustees had absolute discretion over the Trust’s philanthropy, and while they have since given a dab to animal charities, such as Guide Dogs for the Blind, they’ve mostly been targeting people, not canines.